Might Insurance Cover a Breast Reduction in the Presence of Degenerative Disc Disease?

Question

I have spondylosis,stenosis,osteophytes & mild rev of lordosis in my cervical spine to which the drs attribute my pain and numbness. I am 29, had no trauma. I am just starting chiro care. An ortho surgeon rec. fusion surgery, but said there is no danger in waiting. I think at least some if not most of the underlying problem is the weight of my breasts. I am 5'3", 150#, 32F with dense tissue. Would a plastic surgeon be able to determine if that is true? Or is this an automatic "no" from ins?

Kevin Brenner, MD, FACS · Answer

Breast reduction is a common covered benefit under many insurance policies. However, this varies between insurance companies. The first thing that you need to find out from your carrier is if it is a covered benefit. You can contact them directly. If you would like to come in for a consultation, my insurance coordination staff could do that for you as well. The next thing to know is how much of your breast tissue will need to be reduced. This is based on your breast size, height and weight. See the link below for more information.

Craig S. Rock, MD, FACS · Answer

The criteria for an insurance company to provide coverage for breast reduction vary from company to company and plan to plan.  Generally, women who are DDD and larger have enough breast tissue to potentially qualify.  First check the exclusions page of your policy - if breast reduction is listed, it is close to  impossible to obtain coverage (with very few exceptions).  If it is not an exclusion (or if you are willing to fight - usually unsuccessfully), you should see a board-certified plastic surgeon (who is on your plan) for evaluation.  They would be most familiar with the specific additional requirements of your local insurance carrier and plan.

	Good luck.

Tom J. Pousti, MD · Answer

Thank you for the question.

Based on your description you may be an excellent candidate for breast reduction surgery.  The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, spine doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure. This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Make sure you're  working with a well-trained/experienced board-certified plastic surgeon.

Best wishes.

David L. Abramson, MD · Answer

Insurance can frequently cover breast reduction for symptomatic macro mastic. Documentation of tieback problems are frequently necessary

Darryl J. Blinski, MD · Answer

The only way to determine health insurance coverage is having a boarded pS send a predetermination letter to the insurance companies reviewing panel. A witten response is needed to proceed.

Might Insurance Cover a Breast Reduction in the Presence of Degenerative Disc Disease?

Answers (5)